Shirley Health Partnership

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service following its relocation to new premises This key question has been rated as Good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Managers encouraged staff to report incidents, near misses, and safety events. These were discussed in significant event, complaint and learning event meetings to which all staff were invited to attend. Minutes from the meetings were available for staff who could not attend. Leaders scheduled these as a standing agenda item to support continuous improvement. Staff told us there was an open culture where safety was a top priority, and they felt confident to speak up when things went wrong or they had suggestions for improvement.

The service investigated significant events, and evidence seen demonstrated these were completed in line with the service’s policy. The process for reporting events was reinforced by email to all staff regularly. For example, following an incident where clinical results had been allocated to a clinician who was on annual leave, resulting in a delay in contact, the service undertook a review. Learning from this incident highlighted the importance of ensuring that system out-of-office settings are consistently applied to support the safe reallocation of tasks. As a result, a pre-leave checklist was introduced, and administrative staff completed this before clinician leave.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new people registering at the service. The service worked with other providers to deliver shared care when people moved between services. The community nurses we spoke to as part of this assessment confirmed they had timely access to a person’s named GP when needed.

Referrals and test results were managed in a timely way. Staff had a clear understanding of their roles and responsibilities with urgent tasks and results being processed first.

At the time of the onsite visit, there were no outstanding suspected cancer referrals (formerly known as the 2-week wait pathway), and these were prioritised each day.

However, there was a backlog of routine, non-urgent documents which the service had already identified and risk assessed. The service had an action plan to address the backlog and this was being worked through at the time of our visit, with additional hours offered to staff and external resources secured to reduce the backlog.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff who were able to identify their nominated safeguarding leads for both children and vulnerable adults. Staff told us they felt confident in approaching the safeguarding leads for advice. However, at the time of our onsite visit, not all staff had completed up to date, refresher training relevant to their role and in line with the service’s policy. Following our onsite visit, the service provided evidence to demonstrate it had been working to address this, and training completion had improved. Staff we spoke with showed good knowledge of safeguarding children and adults and knew how to escalate concerns appropriately.

The service held a list of vulnerable people maintained and reviewed by safeguarding leads. The service acted on concerns working in partnership with other organisations for example when a child ‘was not brought’ the service had safe systems and processes to ensure children had been appropriately followed up. For example, by telephone and in writing and concerns could be escalated to safeguarding leads.

Safeguarding meetings were held every 3 months by the nominated leads, with all staff being encouraged to attend and contribute to discussions. Staff told us informal discussions were encouraged in addition to formal meetings, and they felt confident approaching leads for support.

The service offered chaperones during consultations, and a member of staff had completed chaperone training. The service used their screens in the waiting room to inform people of the option of a chaperone.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available, well‑stocked and maintained, with daily checklists completed. During our onsite visit, we checked the defibrillator, oxygen supply and emergency medicines, and found the service had the equipment and medicines required to manage medical emergencies and associated risks.

All staffhad completed basic life support training in January 2026. Staff were able to recognise when a person’s condition was deteriorating and understood the appropriate actions to take.

Duty clinicians were available to provide advice and support where required, and the service had an alert function within their system that staff could use to request urgent assistance during an emergency.

People were provided with advice regarding risks associated with their condition and were given clear guidance on what actions to take should their condition deteriorate, for example, to contact NHS111 or attend the local emergency department if they developed worsening symptoms.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service operated from a modern premises that was purpose-built in the last 2 years.

Contracts were in place to ensure the premises were appropriately maintained. Equipment calibration had been completed in February 2026 and was subject to routine monitoring. Planned annual safety checks were undertaken for the fire alarm system, emergency lighting and firefighting equipment which we reviewed on site. The service had appointed fire wardens with appropriate training and had a fire evacuation plan, supported by clear instructions.

Health and safety risk assessments and audits had been completed, and due to the age of the building being less than 2years old, there were no actions currently required of the service. A business continuity plan was in place, monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. Safe recruitment practices were followed. Our review of 3 staff files demonstrated that appropriate recruitment checks had been completed. Whilst not all staff had received DBS checks, risk assessments had been undertaken for those staff members in line with the service’s policy.

Following recruitment, staff progressed through an induction process, which we saw evidence of in staff files, supporting them as they entered their respective clinical or non-clinical roles within the service. Learning needs and development of staff were managed appropriately, with staff working within their agreed areas of competence.

The service provided informal clinical supervision support daily to clinicians. In addition, formal peer review and group supervision meetings were scheduled, and we reviewed the minutes of these. Following our onsite visit, the service provided us with a copy of their formal clinical supervision policy which had been introduced to further strengthen formal supervision.

The service had a system to monitor training completion, and staff were provided with protected time to undertake this. However, our review of training records showed that, while some staff were up to date, and all core training had been completed upon recruitment, training refreshers were not consistently current across the whole team in line with the service’s policy. We identified no knowledge gaps with the staff members we spoke with during the assessment. Following onsite visit, the service confirmed improvements had been implemented to strengthen its training programme oversight, and an updated training matrix demonstrated improved compliance.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The service had a designated infection prevention and control (IPC) lead, and staff were aware of who this was and how to escalate concerns. Appropriate arrangements were in place for the segregation and disposal of clinical waste.

A newly appointed external cleaning company was being used by the service. Daily cleaning records were available and reviewed during the onsite visit, alongside completed environmental cleaning audits and cleaning checklists. The most recent IPC audit was partially completed due to a change in cleaning contractor, with the service planning to reassess the environmental cleaning elements following a settling-in period. Control of Substances Hazardous to Health (COSHH) assessments and safety data sheets were in place and available for review. Throughout the onsite visit, the environment was observed to be clean and tidy.

Personal protective equipment (PPE) was appropriately stocked and readily accessible, and clinical equipment was maintained in a clean condition. Spillage kits were available, and staff knew how to access support if required. The service also had an up-to-date IPC policy in place.

Whilst not all staff had completed up-to-date IPC training as part of the mandatory training programme, staff demonstrated the knowledge required to carry out their roles safely, and leaders were supporting staff to complete outstanding mandatory training through reminders and protected time. Following our onsite visit, the service provided evidence to confirm completion of training had improved.

However, there was no evidence hand hygiene audits were being undertaken in line with best practice guidance or that hand hygiene training compliance was being routinely overseen by leaders. The service did have hygiene guidance available through posters displayed at handwashing facilities and staff instructions were included within the IPC policy.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them to understand how to manage their medicines safely. The service had systems in place to support medicines optimisation, including structured recall, review processes and oversight of prescribing risks.

As part of this assessment, we completed remote clinical searches and reviewed a sample of records to assess how safely medicines were prescribed and monitored.

We reviewed 5 records of the 19 people identified as being diagnosed with asthma and prescribed 2 or more courses of oral rescue steroids in the previous 12 months. Records showed that assessments were completed at the time of prescribing, follow-up had occurred, inhaled corticosteroids were prescribed where indicated, and annual asthma reviews were documented.

The search for people with hypothyroidism who had not had thyroid function tests (TFTs) within the recommended 18‑month period identified 5 people. Records reviewed showed 3 of the 5 people identified as overdue were being actively contacted and invited to attend blood tests, and the other 2 people, the service confirmed they have since invited.

The medicines usage search identified 94 people that were prescribed oral NSAIDs or antiplatelet medicines without a gastro‑protective proton pump inhibitor (PPI) and had no recorded reason for this. (A PPI is a medicine that reduces stomach acid production to shield the lining of the digestive tract). The service provided assurances following our onsite visit that they have reviewed these to ensure prescribing remains appropriate and individualised.

The search for people with diabetes with significantly raised HbA1c levels showed that diabetes reviews and medication reviews had been completed, and people were being followed up appropriately. We identified only 1 person who required a blood pressure review, and the service has since reviewed their process for follow up and ensured all appropriate actions have been taken.

We reviewed 5 of the 54 records the search identified as being prescribed methotrexate, our review showed people in the sample had been contacted to attend the service for blood tests, and alerts and shared care arrangements were in place. However, we noted there were sometimes delays between the last recorded blood tests and follow-up, during which repeat prescriptions had continued.We fed this back to the service for it to address.

The service had arrangements in place to share and respond to medicines safety alerts, with a named individual responsible for disseminating alerts to the clinical team. This supported timely awareness of prescribing risks.

Staff managed prescription stationery appropriately and securely in line with national guidance. Staff kept records of prescription stationery issued and stored unused stationery in locked cupboards. Staff followed protocols to ensure they prescribed all medicines safely.

Temperature checks of clinical fridges storing vaccinations were consistently monitored and documented; staff were aware of the procedure to follow should readings fall outside the recommended range.

All Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were up to date, regularly reviewed and kept current to ensure people received the correct treatment as planned. (PGDs are written instructions that allow healthcare professionals to supply or administer certain medicines to groups of people without a prescription. PSDs are written instructions for an individual person, tailored to their specific health needs).